Module 1: Therapeutic Relationship & Communication
Overview: A therapeutic relationship is purposeful, patient‑focused, time‑limited, and guided by professional ethics.
1.1 Key Concepts
- Empathy vs Sympathy: Empathy conveys understanding (“I understand you’re feeling hopeless—tell me more.”). Sympathy (“I’m sorry you feel that way.”) brings in personal emotion and shifts focus—avoid in clinical responses.
- Therapeutic ≠ Social relationships: Social = mutual benefit. Therapeutic = the nurse’s skills applied toward patient goals.
- Boundaries & Roles: Maintain clear professional limits. Watch for transference and counter‑transference.
1.2 LOSER Acronym (Non‑Verbal Attending Skills)
| Letter | Action |
|---|
| L | Lean forward toward the client |
| O | Open posture (arms uncrossed) |
| S | Sit squarely facing the client |
| E | Establish eye contact (culturally appropriate) |
| R | Relax and listen |
1.3 Therapeutic vs Non‑Therapeutic Responses
| Therapeutic Technique | Example |
|---|
| Open‑ended questions | “How have you been coping with everything?” |
| Reflection | “It sounds like you feel overwhelmed.” |
| Restating | Pt: “I’m exhausted.” → Nurse: “You’re feeling very tired.” |
| Offering Self | “I’ll stay with you while you talk.” |
| Silence | (Purposeful pause to allow thought) |
| Summarizing | “We’ve discussed feeling stressed at home and work.” |
| Non‑Therapeutic Technique | Why to Avoid |
|---|
| Asking “Why…?” | Feels accusatory, increases defensiveness. |
| Giving advice | Devalues patient autonomy. |
| Approval/Disapproval | Shifts focus to pleasing nurse. |
| False reassurance | Invalidates emotion. |
| Arguing / Disagreeing | Escalates tension. |
| Probing questions | May raise anxiety. |
1.4 Phases of the Nurse‑Patient Relationship (Peplau)
- Pre‑Orientation → Self‑reflection, chart review.
- Orientation → Establish trust, set goals, identify problems.
- Working: Identification & Exploitation → Explore stressors, encourage coping, use nurse roles (teacher, resource, leader).
- Termination / Resolution → Summarize progress, evaluate outcomes, foster independence.
Module 2: Nursing Process & Mental Status Examination (MSE)
Overview: The ADPIE framework ensures systematic care, while the MSE (often remembered with ASEPTIC) provides a cognitive snapshot.
2.1 ASEPTIC Breakdown of the MSE
| Acronym | Focus | Examples |
|---|
| A – Appearance/Behavior | Hygiene, posture, motor | Disheveled, psychomotor agitation |
| S – Speech | Rate/volume/coherence | Pressured speech, slurred speech |
| E – Emotion (Mood/Affect) | Subjective & observed emotion | Reports “sad”, flat affect |
| P – Perception | Hallucinations/illusions | Auditory voices, visual shadows |
| T – Thought (Process/Content) | Organization & themes | Loose associations, SI or HI |
| I – Insight & Judgment | Awareness & decision‑making | Poor insight, risky behavior |
| C – Cognition | Orientation, memory, attention | A&O×3, recalls 3 objects |
2.2 Thought Disturbances & Perceptual Changes
- Circumstantial: Excessive detail but answers question.
- Tangential: Goes off topic, never answers question.
- Loose associations: Shifting ideas without logical links.
- Flight of ideas: Rapid flow with superficial links.
- Thought blocking: Sudden stop mid‑sentence.
- Word salad: Random unrelated words.
- Illusions vs Hallucinations: Misinterpretation of real stimulus vs false sensory perception.
- Ideas of Reference: Belief external events relate to self.
- Derealization / Depersonalization: World or self feels unreal.
Module 3: Therapeutic Groups & Community Resources
Group phases are often simplified to Orientation → Working → Termination, and leadership style shapes dynamics.
3.1 Leadership Styles
| Style | Key Features | Pros / Cons |
|---|
| Autocratic | Leader makes decisions | Efficient in crisis / Low group morale |
| Democratic | Shared decision‑making | High engagement / Slower process |
| Laissez‑faire | Minimal control | Freedom / Risk of chaos & unclear goals |
Module 4: Introduction to Mental Health & Legal/Ethical Issues
Updated legal content is critical for safe practice.
4.1 Key Statutes & Policies
- Baker Act: Involuntary hold for mental health crisis.
- Marchman Act: Involuntary hold for substance abuse.
- RTR – Right to Request Discharge: Provider must assess within 24 hrs.
- Tarasoff Law / Duty to Warn: Obligation to notify identifiable victim of threats.
4.2 Restraint Protocol (Adult)
| Requirement | Details |
|---|
| Emergency Application | Allowed without order if danger is imminent. |
| MD Evaluation | Must occur within 1 hour. |
| Order Duration | Valid 4 hrs, renew per policy. |
| Vitals | Monitor & document every 15 min. |
| ROM/Toileting | Offer every 2 hrs. |
| Documentation | Behavior, interventions tried, patient response. |
4.3 Suicide Risk Decision Flow
Patient mentions suicidal ideation (SI)?
└─► Ask directly about plan, means, intent
├─► If plan/means present → 1:1 observation, remove hazards, notify provider
└─► If no plan → Continue frequent checks, develop safety plan, reinforce supports
Module 5: Conceptual Models & Therapeutic Approaches
5.1 Neurotransmitter Imbalance Matrix
| Disorder | Neurochemical Imbalance |
|---|
| Depression | ↓ Serotonin, ↓ Norepinephrine, ↓ Epinephrine |
| Anxiety | ↓ GABA, ↑ Norepinephrine |
| Schizophrenia | ↑ Dopamine, altered Serotonin |
| Bipolar Disorder | ↑ Glutamate, altered GABA |
Module 6: Substance Use & Abuse
Key enhancements: withdrawal timelines, medication options, and specific risks.
- Alcohol Withdrawal Timeline: 4‑8 hrs (tremor) → 12‑24 hrs (seizure) → 48‑72 hrs (DTs).
- Opioid Withdrawal: Onset 6‑8 hrs, peak 2‑3 days, not fatal.
- Medication Highlights: Methadone, Buprenorphine, Naltrexone for opioid; Disulfiram & Acamprosate for alcohol.
- Inhalant Risk: “Sniffing death” → possible sudden cardiac arrest.
Module 7: Thought Disorders (Schizophrenia Spectrum)
7.1 Phases of Schizophrenia
- Pre‑Morbid: Subtle cognitive/motor deficits before symptoms.
- Prodromal: Social withdrawal, odd ideas; months‑years.
- Schizophrenia (Active): Positive symptoms prominent.
- Residual: Remission—negative symptoms may remain.
7.2 Responding to Hallucinations
Do not reinforce hallucinations. Acknowledge experience, present reality, and gently redirect to here‑and‑now activities.
Module 8: Mood & Depressive Disorders
8.1 Bipolar Disorder – Mania vs Depression
| Feature | Mania | Depression |
|---|
| Mood | Euphoric/Irritable | Sad/Hopeless |
| Energy | Hyperactive | Fatigued |
| Sleep | Minimal need | ↑ or ↓ |
| Thoughts | Flight of ideas, grandiosity | Suicidal ideation, guilt |
| Behavior | Risky spending, impulsive | Withdrawn, neglect ADLs |
| Nursing Care | Finger foods, limit setting, safe milieu | Assess SI, structured routine |
8.2 Treatment Phases for Major Depressive Disorder
- Acute (6–12 weeks): Goal → symptom relief, ↑ function.
- Continuation (4–9 months): Goal → prevent relapse.
- Maintenance (≥ 1 year): Goal → prevent future episodes; may taper meds.
8.3 Non‑Pharmacologic Therapies
- Light therapy for Seasonal Affective Disorder (SAD).
- St. John’s Wort (caution for serotonin syndrome).
- ECT for severe, treatment‑resistant depression—provide seizure precautions.
Module 9: Special Populations & Eating Disorders
9.1 Eating Disorders Comparison
| Feature | Anorexia Nervosa | Bulimia Nervosa | Binge Eating Disorder |
|---|
| Body Weight | BMI <18.5 | Normal–overweight | Often overweight/obese |
| Behavior | Severe restriction, exercise | Binge–purge cycle | Recurrent binge, no purge |
| Physical Signs | Lanugo, amenorrhea, bradycardia | Teeth erosion, parotid swelling | Weight gain, GI discomfort |
| Complications | Refeeding syndrome, arrhythmias | ↓ K⁺, GI tears | Obesity, DM II |
| Treatment | Gain 2–3 lb/wk, CBT, meal monitoring | Monitor around meals, CBT | CBT, coping skills, support groups |
9.2 Refeeding Syndrome
Rapid introduction of calories → insulin surge → intracellular shift of electrolytes (↓ phosphate, ↓ potassium, ↓ magnesium) → risk of cardiac failure. Treat slowly, monitor labs, add supplements.
Module 10: Anxiety & Related Disorders
10.1 Levels of Anxiety
| Level | Characteristics | Nursing Interventions |
|---|
| Mild | Sharp focus, nail‑biting | Teach coping, relaxation |
| Moderate | GI upset, shaky voice | Calm guidance, deep breathing |
| Severe | Dizziness, sense of doom | Stay, reduce stimuli, grounding |
| Panic | Pacing, hallucinations | Safety first, simple phrases, PRN meds |
10.2 Anxiety & Obsessive‑Compulsive Related Disorders
- Separation Anxiety Disorder – extreme distress away from attachment.
- Specific Phobias – e.g., monophobia, zoophobia, acrophobia.
- Hoarding Disorder – difficulty discarding possessions.
- Body Dysmorphic Disorder – preoccupation with perceived defect.
Module 11: Personality Disorders
11.1 Cluster Overview
| Cluster | Characteristics | Disorders |
|---|
| A – Odd/Eccentric | Social detachment, suspicion | Paranoid, Schizoid, Schizotypal |
| B – Dramatic/Erratic | Emotional, impulsive, attention‑seeking | Borderline, Antisocial, Histrionic, Narcissistic |
| C – Anxious/Fearful | Fearful, need for control, dependency | Avoidant, Dependent, OCPD |
Nursing Pearls: Consistent limit‑setting, team communication, monitor self‑harm, maintain neutrality.
Module 12: Cognitive & Memory Disorders
12.1 Delirium vs Dementia
| Feature | Delirium | Dementia |
|---|
| Onset | Rapid (hrs–days) | Gradual (mos–yrs) |
| Course | Fluctuating | Progressive |
| Cause | Medical condition | Neurodegenerative |
| Reversible? | Often | Rarely |
12.2 Alzheimer’s Stages & Cholinesterase Inhibitors
- Mild: Memory lapses.
- Moderate: Personality changes, ADL help.
- Severe: Full assistance, loss of speech/mobility.
Donepezil, Rivastigmine, Galantamine may slow decline—monitor for GI effects and syncope.
Module 13: Abuse & Neglect Across the Lifespan
Remember the cycle of violence: Tension‑Building → Acute Battering → Honeymoon.
- Obtain written consent before touching rape survivors.
- SANE Exam: No showering prior—preserve DNA.
- Mandatory Reporting: Suspected child, elder, or vulnerable adult abuse.
Module 14: Family Interventions & Community Support
Healthy family systems foster recovery; dysfunctional patterns may require therapy, education, and community resources.